Monday, March 29, 2010

Self Regulation and Tort Reform

John Yoo and Jay Bybee were the lawyers who provided the sham legal cover for the Bush/Cheney torture machine. The original draft of the Office of Professional Responsibility (OPR) report had determined that Yoo, Bybee, et al had committed grievous misconduct in their legal reasoning and advice and recommended that they be remanded to their state bar associations for possible discipline and/or disbarment. Of course, in the final version of the OPR report, Yoo and Bybee, although severely reprimanded by Associate Deputy Attorney General David Margolis, were ultimately cleared of providing "intentionally false arguments that they knew to be wrong". In the original OPR report, Yoo and Bybee were determined to have failed "to exercise independent legal judgment and to render thorough, objective, and candid legal advice." Apparently this basic standard of professionalism was deemed by Margolis to be too high a bar. Margolis instead argued that since Yoo was an ideologue who truly believed in what he was saying, then it wasn't his fault that the advice he gave was factually and legally false. Intention to harm is all that matters to Margolis. This is the low standard of professional conduct that an accused lawyer can always appeal to when his or her license is on the line. The blogging lawyer Jack Balkin has an excellent review of this fiasco here:
It's not about what people should do, but about how badly they have to screw things up before they are subject to professional sanctions.

Instead, Margolis argues that, judging by (among other things) a review of D.C. bar rules, the standard for attorney misconduct is set pretty damn low, and is only violated by lawyers who (here I put it colloquially) are the scum of the earth. Lawyers barely above the scum of the earth are therefore excused.

This got my mind revving about medical malpractice reform. It's very clear that malpractice litigation, as currently constituted in this country, is harmful to doctors, patients, and the country's fiscal well being. Frivolous lawsuits lead to defensive medicine and all its attendant costs, in addition to creating an uneasy, antagonistic dynamic in the doctor/patient relationship. Patients who are harmed by bad doctors generally are not compensated for their injuries. (One study determined that only 2% of negligent adverse events occuring in a hospital resulted in a med mal claim.) It's a bad system. The only ones who seem to benefit are the plaintiffs attorneys and the defense lawyers for the big med mal insurance companies. It's a cash machine.

From the perspective of a practicing physician I would like to see reform take several iterations. I think these cases need to be tried in specialized "health courts", with the evidence weighed by independent panels comprised of physicians and lawyers and a judge familiar with medical standards. This way, you eliminate the wild west system of the "show" where hired gun physician expert witnesses argue that "obvious negligence" has occured while others argue the exact opposite. I think any potential malpractice litigation ought to be screened by an indepedent advisory board that would determine the validity of said claim. This would create a mechanism for weeding out those frivolous cases that a doctor has to address via his defense attorney in our current system. It would reward physicians who follow best evidence guidelines and shield them from the lottery system of a med mal trial. I'm also in favor of altering the evidenciary standard in medical malpractice cases from "preponderance of evidence" (which merely implies that malpractice was more likely than not to have occured) to one of "clear and convincing" evidence (a standard just below "beyond a reasonable doubt" in criminal cases.) I'm not so attached to the idea of capping damages. For one thing, caps only benefit insurance companies. Ask any doctor--- it doesn't matter if you're sued for a million bucks or $50,000, the mere fact of "being sued" alters one's future practice patterns rather than the gross dollar amount of the judgment. So I don't think capping the damages will have any appreciable effect on the scourge of defensive medicine. I do, however, like the idea of pre-determined awards that victims are slotted into based on the kind of injury sustained, victim age, and lost wages. This would all be calculated as part of the compensatory aspect of the verdict. The unlimited punitive damages phase of the verdict serves no purpose other than to line the pockets of the plaintiff's attorney.

Those are just a few ideas. I have a future post brewing that goes into more detail. But for now, those are my preliminary thoughts.

The point of this post is to correlate the Yoo/Bybee nonsense with med mal reform. As physicians, we have particular interests and goals with regards to medical malpractice reform. Overall, I think there is broad based support for what physicians desire. But we have to be reasonable about our entreaties. We have to approach the negotiating table in good faith. What can we do in return for arriving at some judicious accomodation? (You know, sort of like what the AMA ought to have been doing all last year instead of stridently, but vaguely, screaming about tort reform tort reform tort reform!)

Here's what we can offer: A renewed dedication to improving professional accountability. Via the state medical boards, medical societies, hospital QA committees, and intra-departmental morbidity and mortality meetings, we need to do a better job of holding those doctors accountable who fail to meet basic standards of care. Our ranks are infested with our own Yoos and Bybees. We need to police ourselves better. And not merely by using some statistical rubric devised by some hospital risk management executive. (Stats don't tell the whole story. Doctors who realize that they will be judged solely on outcomes will seek to eliminate those patients who are more likely to result in bad outcomes, i.e. the suburban hospital that shunts all redo CABG's to the main tertiary center, thus improving their "statistical superiority".) It needs to be done on a case by case basis. It will be labor intensive. Bureaucracies will need to be created. There will be errors and missed opportunities for intervention. But we need to do something. To serve as a practicing physician is a privilege, not a god given right, no matter how many diplomas you have hanging from your wall. You have to re-earn it every single day, with every new patient who walks through your door.

To lose your medical license, or even to be suspended or face disciplinary measures for failing to meet the bare minimum standards of care happens far too rarely in this country. You basically have to show up drunk or drug addled, repeatedly, or to have so many complications that the local newspaper does a story on you and your injured patients in the metro section for there to be any consequences. The bar is set too low, in other words. Denial doesn't help matters (ask the Vatican right now). We need to subject ourselves to a higher standard than what we've held our members heretofore. The surgeon who has four bile leaks in a year maybe needs to have another board certified surgeon watch his technique for his next ten cases. The internist whose diabetic patients develop an inordinately high rate of foot ulcers and have elevated hemoglobin A1c levels perhaps ought to be forced to enroll in some didactic session or a CME course on proper diabetic management.

I don't have the exact plan for how all this is to be enacted. I'll leave that to the AMA, hospital QA committees, and perhaps even federal oversight to determine how we self-regulate ourselves. But the point is that we have to make a move toward greater transparency and better quality assurance. This is the price of any meaningful tort reform. The standards we as physicians hold ourselves to have to be higher than the low bar set by trial lawyers, right?

Friday, March 26, 2010

Spring in the Rust Belt

Hey look---it's a bunch of hippies jamming in the sun. Who doesn't love that? Finally warming up here in Cleveland. Hope all have a satisfactory weekend.

Thiessen Repudiated

The must read piece of the week is Jane Mayer's almost effortless smack down in the New Yorker of torture apologist extraordinaire Marc Thiessen's ridiculous new book "Courting Disaster". You almost feel bad that such a prominent, well-regarded actual journalist like Mayer is forced to wade through Thiessen's compendium of lies, falsehoods, and distortions in order to set the record straight. But somebody had to do it; Thiessen's revisionist history sits atop the NY Times best seller list.

The more interesting question is--- when is President Obama going to start "looking backward" to find out the truth surrounding America's dark torture secrets and hold accountable those who implemented and carried out a shameful program of barbaric, ineffectual, and illegal torture and indefinite detention.

By now I think we can all acknowledge that Obama's greatest strengths are his tenacity and his patience. This HCR triumph took a hell of a lot of courage. He spent an enormous amount of political capital. But he won the long battle. I hope his intention is not to bury the Cheney embarassment, but to revisit it at a later time, once he rings up another couple of victories, i.e. financial market reform. I hope he wins the long battle against the Bill Kristol/Cheney/Thiessen cabal as well.

As Mayer writes:
By holding no one accountable for past abuse, and by convening no commission on what did and didn’t protect the country, President Obama has left the telling of this dark chapter in American history to those who most want to whitewash it.

Wednesday, March 24, 2010

Palliative Care: An Overused Subspecialty?

The #1 Dinosaur has a provocative post from last week about palliative care medicine. Her point is that, too often, primary doctors neglect their duties as physicians and pawn off the undesirable aspects of comprehensive care (end of life issues, vague abdominal pains, constipation, depression/sadness) onto specialists.
Excuse me: why do you need a brand-new "Team" to treat symptoms and talk to families?

True palliative care -- the management of symptoms -- is part and parcel of everyday medicine. Itching; nausea; constipation; pain. Work them up to make sure there is no serious underlying problem, of course, but for crying out loud, don't tell me you now need another specialist to actually come TREAT them! This is fragmentation of care taken to outrageous extremes.

Her argument is compelling. And the dialogue that ensues in the comments to the post (from Palliative Care docs like Christian Sinclair and Eric Widera) is equally persuasive. I fall somewhere in the middle. I agree with Dinosaur to a certain extent that primary care docs need to be more aggressive in addressing end of life issues, even when the patient is ostensibly healthy. You don't want to wait to discuss hospice plans until you're intubated in some random ICU with numerous liver metastases wracking your body. The problem isn't entirely the fault of internists and family practice docs lacking the courage to compassionately address terminal issues, however. Most doctors simply aren't certain of how to navigate this senstive terrain. Medical students aren't exposed nearly enough to the philosophy and psychology of death and dying. (Do we really need to spend four weeks during the second year memorizing the differences between Freudian, Jungian and Piagetian psychobabble?) Furthermore, all residencies, no matter what the specialty, need to incorporate either a rotation on a palliative care floor or multiple intensive didactic sessions dedicated to end of life issues and pain palliation options. (General surgery residents would especially benefit.)

On the other hand, sometimes it's nice to have a palliative care "team" available for those truly futile cases to give the patient and their family additional perspective. I have a tendency to stay optimistic about a case for too long sometimes--- I'm always strategizing ways to "make the patient better", longer than what the objective clinical data warrants. When futility is too obvious to ignore it's sometimes very difficult to make that transition, as a surgeon, from aggressive advocate of healing to the voice of realistic resignation. It's hard for me and it's hard for the families involved. It can seem as if I've too suddenly changed my mind, which can trigger doubt (in my judgment, my clinical expertise, etc) in the minds of the patient and his loved ones. So I have found it is constructive to say to a patient's family, "you know, things don't look so great right now. It's becoming apparent your mom is not pulling through the emergency surgery the way we had hoped. I think it would be helpful for you all to speak with the people from our palliative care team, to hear a different perspective, and maybe then we can reconsider our options." It just helps smooth the transition from the full-court press of intensive treatment to the more realistic phase of saying goodbye.

Bath Time!

Archives has a retrospective review this month from a level I trauma center in Canada that studies the effect of daily bathing with chlorhexidine solution on the development of infectious complications in ICU patients. 286 patients were studied over 6 months. Here are the essential results:
Patients receiving chlorhexidine baths were significantly less likely to acquire a catheter-related bloodstream infection than comparators (2.1 vs 8.4 infections per 1000 catheter-days, P = .01). The incidence of VAP (ventilator associated pneumonia) was not affected by chlorhexidine baths (16.9 vs 21.6 infections per 1000 ventilator-days in those with vs those without chlorhexidine baths, respectively, P = .30). However, patients who received chlorhexidine baths were less likely to develop MRSA VAP (1.6 vs 5.7 infections per 1000 ventilator-days, P = .03). The rate of colonization with MRSA (23.3 vs 69.3 per 1000 patient-days, P < .001) and Acinetobacter (1.0 vs 4.6 per 1000 patient-days, P = .36) was significantly lower in the chlorhexidine group than in the comparison group.

The ICU nurses are just going to love this paper. Nothing fires them up more than the anticipation of doing a head to toe sponge bath on an inert, intubated patient in the ICU that takes four people to roll from side to side.

Tuesday, March 23, 2010

Reader Dissent

A reader named "J" wrote a comment on my post supporting health care reform from last week that I thought would be enlightening to re-post in full:
Buckeye, I'm surprised at this post. After all, not too long ago, you had a well-timed post against your being taxed at an unreasonable rate (see "Welcome to the Real World"). Why the change of heart? An additional tax on those making $200,000 and more, reduced Medicare reimbursements, new, expanded Medicaid obligations in state budgets, a 40% tax on existing "good" medical plans, new excise taxes on tanning salons, pharmaceutical companies, device manufacturers, and health insurers (ultimately passed on to the end users). Buckeye, if any significant amount of your business is Medicare, your reimbursements are going down while your taxes go up.

This bill proposes a shotgun fix in the wake of a majority in both houses of Congress and the midterm elections. This is not a problem that can be solved by this bill. The American Academy of Family Physicians predicts a 40,000 shortage of their own pedigree by 2020. Let's consider the numbers further: it takes at least 7 years to train a physician. Our current physicians are expected to take on 32 million new customers by 2014. Nurse practitioners and PAs are looking to fill this gap in care, making doctors in primary care less relevant. In fact, nurse practitioner programs are transitioning to offering only doctoral programs to "be on the same parity of respect with doctors." Nurse anesthetists on average now earn more than the average family practitioner.

The mandate for insurance has few teeth. For an individual, a $95 penalty in 2014 increasing to $695 by 2016. Is there a health plan that costs $695 a year? Guaranteed issue of health insurance only works with enough payees, and this penalty is not exactly an incentive to purchase a policy.

The solutions are not pretty, but when taken in small doses, like sips of alkaselzer, you have measurable progress. First, fund more residency positions in primary care to take on the additional patients. Then implement guaranteed issue of health insurance with a stronger purchase mandate. Leave the feds out of modifying health premiums, otherwise every federal official will run on lower health premiums without regard to solvency. Allow states to recover if adopting the unfunded mandate of expanded Medicaid eligibility and greater reimbursements. Oh, and what about tort reform?

J's points are well taken. There's no doubt that health care reform, in its present iteration, will not be a financial bonanza for physicians. It will alter our income expectations for the next several generations. We'll pay more taxes. Reimbursements will steadily decline (how do you think this bill will be able to maintain any illusion of fiscal sanity?). There's no tort reform (other than $50 million set aside for the study of undefined "pilot projects"). There's nothing in it to permanently address the medicare SGR cuts. Subsidies for medical school education and financial incentives to entice medical students into choosing primary care are curiously absent. There was no special interest group involved in this year's long HCR debate who came away from the final deal with less than us physicians. We got hosed. Some of it is our own fault. We're a disjointed, politically diverse group of professionals. Furthermore, our big lobbying arm (the AMA) proved itself to be an impotent, ineffectual voice at the bargaining table. What's done is done.

So why do I still support the passage of Obamacare? This is going to sound awfully pretentious, but I can't help it--- the moral argument for reform, any sort of reform, is just too powerful. Basic health care ought not to be dependent on market cycles or employment or whether or not you have a pre-existent disease. Americans ought to be able to go the hospital, see the doctor and not worry that the treatment they receive could potentially lead to financial ruin. It's just not right. I have a young patient right now who is going to benefit enormously from the passage of the bill. She's a 21 year old physics major who wants to go to grad school and eventually teach at her local community college. A few months ago, she presented to the hospital with free air and peritonitis. She had perforated her colon, secondary to what ultimately was determined to be Crohn's disease. She has a colostomy and wants to have it reversed as soon as possible. Her health insurance through her mom is due to run out in May. But with the passage of the bill, she can stay on her mom's plan until she's 26. We don't have to rush the colostomy reversal surgery. We can take our time. Make sure she's completely healed. Furthermore, let's say she gets that PhD in physics in a few years but she doesn't score a job right away. Maybe she teaches for a year or two at a private high school on a contingency basis, without benefits. How is she going to buy her own health insurance as an individual? She has Crohn's disease! Who would insure her?

Closer to home, my own mother lost her job at Akron Children's Hospital last year. She'd worked there 25 years. She's not quite old enough to qualify for Medicare. Her COBRA plan runs out in the fall. What is someone like her supposed to do?

We have to help each other out, dammit. It's more than tax brackets and socialism and redistribution of wealth. This is health care. It's life. It's the people around us, the ones we love.

Is it a perfect plan? Hell no. But it would be more useful to look at it as a stepping stone to something better. What I'm hoping is that the Republican Party uses this perceived defeat as motivation to renounce their heretofore obstructionist, denialist stance and get off their asses to propose additional reforms. The GOP hates Obamacare. That's been clear enough for a year. So do something about it! Add to it. Make it better. Get tort reform in there. Do something about the primary care/general surgeon shortage and medical school debt. This HCR bill is a paragon of centrist principles. There's no single payor. This is not government takeover. It isn't anything like what the noise machines on Fox and Rush Limbaugh would have you believe. It's simply an initial foray into a more just society...

David Frum (conservative pundit, American Enterprise Institute fellow) has a nice piece on CNN articulating a possible GOP game plan in response to the passage of Obamacare.

Thursday, March 18, 2010

Annals of Dumb Science

This article from JACS attempts to solve the historically vexing surgical conundrum of whether double gloving has a negative impact on manual dexterity. A lot of surgeons I know double glove for both safety reasons and to theoretically reduce infectious complications (studies have shown that gloves develop at least micro-perforations after 30 minutes of operating time). I personally don't double glove. My fingers get numb after about fifteen minutes, for one thing. For another, it just "doesn't feel right". I don't feel comfortable. I hate it. So I wear one layer of the orthopedic gloves, which are a little thicker than the standard glove.

This article in JACS utilized pegboards and sharp pointy tips and whatever else to compare dexterity and tactile sensitivity scores of participants wearing either two gloves or one. I just love scientific phrasing: "Categorical and continuous variables were identified, general linear prediction models were computed, and the influence of glove status was analyzed as an independent variable. Glove status did not affect dexterity performance scores (p = 0.57) after accounting for the influence of age on score variation (p < 0.001). Comparing ulnar and radial surfaces of the index finger for 2-point discrimination, no difference was detected between trials (p < 0.66), nor was an interaction effect detected with glove status (p = 0.40)." Well that's great. Their little study showed no difference in the scores in either group.

Anyone with at least 14 functional brain cells ought to look at an article like this and say: Who cares! The kind of gloves you wear and how many layers you prefer is an entirely subjective decision making process. Are people who like wearing one glove going to all of a sudden change? Are they just going to be so overwhelmed by the rigorous science of the article they they will feel utterly compelled to pull on another layer of gloves?

I mean, you could put together a gazillion studies like this, relating to subjective operating experience. How about a study that compares manual dexterity in surgeons wearing Prada sunglasses vs. a control group? Or one comparing surgeon error rates when the temperature in the OR suite is 85 degrees vs. 65? How about one that compares the manual dexterity of surgeons in boxers with those in tighty whiteys vs. another group that goes commando? Would results change surgeon underwear preferences in the future?

I realize these journals have to fill their content quotas every month but sometimes it gets a little ridiculous.

An Analogy

The Washington Post's new resident hack/torture-apologist Marc Thiessen had an article last week defending the disgraceful attack ad put out by Liz Cheney/Bill Kristol et al which implied that attorneys who defended Gitmo detainees in habeas corpus petitions were essentially Al Qaeda sympathizers. This abhorrent attack on the motivations and ethical character of a group of lawyers has been thoroughly discredited by pretty much everyone along the political spectrum, right and left wing. Further, Thiessen argued that there was some sort of "double standard" being practiced by the "liberal media" in how the authors of the torture memos, John Yoo and Jay Bybee, were universally condemned for their role in justifying and perpetuating the Cheney torture and rendition program with their shoddy, discredited legal reasonings, while the DOJ lawyers involved in the Gitmo cases have been "let off the hook".

The intellectual and moral vacuousness of his thesis is just mind blowing. Let me give you an analogy that will help elucidate the stupidity of Marc Thiessen.

According to the OPR report, Yoo and Bybee were found to have committed "intentional professional misconduct". (Yes, I know, David Margolis from the DOJ rejected this finding independently thus ensuring that Yoo and Bybee wouldn't risk possible disbarment--- but that's a blog post for another time.) The Gitmo lawyers, on the other hand, provided counsel to detainees who may or may not have been guilty of conspiring with terrorists. We already know that hundreds of people detained over the years at Gitmo have been released without any charges being filed, without any evidence that they were terrorists. In other words, there were innocent people in Gitmo. That's an incontestable fact. In this country, when trying to determine the guilt or innocence of a prisoner/detainee we go through a process called a fair trial. Even in military tribunals. That means both sides present their cases and lawyers argue the merits of opposing claims under strict and fair guidelines. I know it's hard to believe, but that's the way we do things in the United States of America.

So there is no equivalence between trashing Yoo/Bybee and doing the same to the Gitmo lawyers. There is no double standard in play.

What Thiessen is claiming would be like equally condemning a surgeon who wantonly shows up drunk for a case and operates on the wrong leg with a trauma surgeon who electively (and pro bono) operates on a suspected drug dealer who rolls in with a gunshot wound to the belly. Would anyone really question the ethical composition of that trauma surgeon who chose to fulfill his duties as a professional, regardless of any personal enmity or judgement he may feel toward the patient? Is that trauma surgeon truly the same animal as the drunken hack who harms the patient?

Thiessen is criminal, a lower level enabler of the Cheney machine, but a criminal nonetheless. And a once proud journalistic enterprise now publishes and pays him for his disjointed, morally dubious drivel....

Wednesday, March 17, 2010

I'm Sold

Health care reform needs to pass. I'm sorry. It just has to. This transcends politics and ideology and all the other b.s we have to listen to on FoxNews and CNN. It's become one of the defining moral issues of our time (along with the torture scandal, of course.) This article from the NY Times puts things in perspective: Study Finds 1 in 4 Uninsured in California. And I wanted to highlight a full quote from one of the commenters in the article.
I have been working as a freelance marketing writer in Silicon Valley for the past ten years and am now age 62. The premiums for somebody my age, though I am in good health (so far) would be wallopingly high --- if I could even get insurance. However, nobody will touch me because of my age, even at ruinous rates. My income is up-and-down in this economy; when business is good, I am able to pay as I go for basic exams and preventive care and the odd case of the flu. But other times I have had to borrow on my car's pink slip to pay medical bills and even my rent (a brutal 99 percent rate of interest!) And my good health could change in the blink of an eye, of course. Pretty scary.

I am not able to get full time work with benefits despite my efforts. Companies know that they have people like me over a barrel, so they hire us as 1099s with no benefits, and we grab every bit of work we can get, you may be sure.

I recall my health insurance premiums back in the early 2000s were only $250 a month through Blue Shield. I could always scrape that together. But I am uninsured now. I have deep experience and an education from a top university, but I have no security at all. I plan to keep working until I drop in my traces. Am I not worth basic medical insurance?

The story is heartbreaking. How is it that we've determined that the provision of basic health care to our citizens is just another commodity, availability to be determined by market forces and "principles of free enterprise"? Socialism you say? Government takeover? What about those highways you take to work? Or the museums and public parks you visit to refresh your soul? Or the elementary school you send your kids to around the corner? Or the police and fire departments that we depend on in communities across the land? Or the little social security check your elderly parents receive? How thankful are you that granny has Medicare? These are all publicly funded programs, people. They represent the unacknowledged "socialistic" impulse that pervades our nation's moral soul. A long time ago we decided that no child should be without an opportunity to receive a basic education. It was such an obvious ethical conclusion that there has never been much opposition to the idea of using public funds to provide for the schooling of its youth. Granted, there are inefficiencies and injustices. We have a tiered system. Urban, inner city schools are poorly funded and ambivalently managed. But at least a kid growing up in inner city Chicago has a school to go to!

How is it that we have collectively excluded the provision of health care to its working citizens and children from the category of public goods that are justifiably paid for by public funds? Why are we ok with pooling our resources to pave our roads every two years but if you propose to disconnect the ridiculous, anachronistic symbiosis between health care and employment, you're called a communistic nazi? It just makes no sense.

The reform bill pending right now is about as watered down a version of reform as you will ever see. There is no public option. The private health insurers are happy. Big Pharm has been paid off. Doctors are going to get screwed. But anything bolder or more egalitarian would stand no chance. The FoxNews/GOP noise machine has already won the PR battle. Obama is a socialist. Goverment takeover. He's going to steal your Medicare. Ultimately, the bill won't be good enough (doesn't include all 47 million uninsured, too many concessions to corporate America, too much faith in cost control prognostications), but at least it represents a step in the right direction. I know, that sounds passive and patronizing----at least it's something, blah blah blah. But we have to stop averting our eyes from unpleasant facts. The time to intervene is now. If it fails, no one will touch health care reform for another generation....

Good article from Health Affairs Blog advocating for reform.

Thursday, March 11, 2010

Hold, please...

Time for a rant.

When you call a hospital's main line these days, while you're waiting to be connected to the department you want, they don't play muzak anymore; what you hear is instead some testimonial or advertisement about the wonderful greatness of the hospital you've called. At Memorial Hospital we offer the highest quality care, the latest fancy dancy machine/robot...blah blah blah. For a while, my hospital was touting the miracle of the DaVinci Robot on its pre-recorded hold message. I think every hospital in the country that invested in the Da Vinci has that one. The last couple of weeks, however, I've heard messages that sort of stunned me.

The first one was a pronouncement that my hospital now is being covered by "highly trained pediatric surgical specialists to provide the highest quality of care for your children." Pediatric surgeons from a certain monolithic medical conglomerate are now covering ER calls at my hospital. And I ask myself: why? Prior to this development, all pediatric surgical cases went to the general surgeon on call. Basically this meant that we did a lot of lap appendectomies and drained soft tissue abscesses and took out the occasional gallbladder in an obese 17 year old. You know, bread and butter surgical stuff. How exactly does a pediatric surgeon add anything to the mix? Now don't get me wrong I can appreciate what a pediatric surgeon can do. But my hospital doesn't even have a NICU or a PICU. We just don't have the ancillary capabilities to take care of kids with congenital diaphragmatic hernias or pyloric stenosis or malrotation cases. It just doesn't make any sense from a medical perspective. From a marketing perspective, though, it makes all the sense in the world. Now you can go to the community hospital when your kid has appendicitis and a specialist will be available to remove it. How about that? I mean I get it. I just think it's misleading and disingenuous.

The other hold message was one proclaiming our designation as a level II trauma center, but the way it was phrased gave me pause. The voice intoned-- "this is the 2nd highest ranking a trauma center can attain." What the hell does that mean? Is this some sort of BCS system? Are we ranked 2nd in the AP and 3rd in the coach's poll? It's absurd. It isn't a ranking. It's just a way to communicate the level of trauma care a hospital is able to provide. Level one trauma centers have attending trauma surgeons in-house at all times. As a result we can quickly funnel most major traumatic injuries (gunshot wounds, complex pelvic fractures, etc.) to the appropriate facilities.

Anyway, I just hate the way marketing has infiltrated the practice of medicine in such a way that it obfuscates the true meanings of words and concepts.

Tuesday, March 9, 2010

The Connection

It's worth your while to browse through Sid Schwab's sampler one rainy Saturday afternoon when you get a chance. The old man can write. I was reading through a couple of his old posts the other day when I stumbled upon this one. It's a shorter post (for him) but very powerful and moving. He describes what it's like to enter an abdominal cavity of a patient, with all its metaphysical implications:
I will reach in gently and caress the liver, the stomach and spleen. Slide over the top, into the recesses, curl the fingers enough to sense the texture, the fullness. The bowels move away and under, and over the top as I direct my hand. I can describe your kidneys now, I've circled the top of your rectum, held your uterus, measured your ovaries between my fingers. Part of you is gone at the moment, but I'm here, I know you now. You trusted and let me in, you opened your belly to me, and I entered with force. I'll stay until it's right. It's what I must do. You think you'll never touch me so intimately as I've touched you. But you have. You have.

It's beautifully rendered. But reading it, I kept feeling this nagging disconnect between what Doc Schwab feels and the way I feel when I perform surgery. He seems to suggest that the invasion of surgery brings him closer to a patient, allows him to connect with him in a deep and meaningful day that transcends anything that occurs when the patient is conscious. It's funny, I don't feel anything like that at all. I actually never feel further from the patient, as an individual, than when they've been put under anesthetic and I'm calling for the scalpel. The patient as I know him disappears the minute I put my mask on. He doesn't exist anymore. It sounds terrible but let me explain. Trust me, I'm not some Mengele slicing and dicing my way through a bunch of mere specimens.

Doctors and patients establish relationships. That's not a controversial statement. Roles are played, boundaries are delineated. The patient seeks wellness and the artful physician hopes to provide it with equanimity, humility, and excellence without compromising the patient's dignity. It's a simple transaction that occurs in the light of day. There are no hidden agendas in this game. We're talking about a rare human moment of openness, vulnerability, and non-judgemental compassion. It's the real deal. And that's why, for all the strife and stress and inconvenience of modern medical practice, it's still the best job in the world.

The strange thing about being a surgeon, for me at least, is that my time in operating room is not so much a continuation of that relationship as it is a temporary rupture in the connection. The patient ceases to exist for me as they do while conscious. The sterile drapes are placed, the face is hidden, all I see is the pale white glare of exposed flesh under OR lights. A small segment of working space in which to intervene, repair, remove. There is no connection anymore between what I see and experience in the OR and the the person who was nervously smiling in the preop holding area a half hour prior. A certain objectification of the patient occurs for me and it's unconscious and automatic. I can't help it. Even the individualized aspects of the operation----the way this liver feels compared to another, the inflammation of one gallbladder compared the the previous patient, the toughness of the skin of a younger patient and how I have to press the knife with force versus the parchment-like gossamer skin of the elderly and the light passage of the blade like I'm tracing my name in the icing of a cake--- none of that is translated to how I perceive the individuality of the patient outside the operating room. I file away the memories of the cases, certainly; the subtle variances in anatomy, different approaches I've taken to handle unexpected problems, but I don't attach those details to the patient. The disconnect is complete. I don't feel touched by a patient while I operate. I don't have time for that sort of sentimental softness. It's all business in the OR. I have a job to complete. A gallbladder to remove. A hernia to repair. A cancer to resect. An artery to ligate. These things need to be accomplished with a certain cold and dispassionate technical excellence. You can't afford to have your mind clouded by invasive knowledge of what that person is like outside the confines of the OR suite. I can't afford to be thinking about how the patient likes Twizzlers for breakfast or has bad breath or always seems to have lipstick on before I make rounds at 6:30 AM or has twin 3 year old girls named Kiley and Kelly or how she raises alpacas for some reason or how he loves Dale Earnhardt Jr or how she has to drive her elderly husband around town all weekend because he has the "maklar generation". I can't be distracted by that stuff when I'm operating. I fall into a pleasant trance of technique and purposeful movement. The patient fades from view, further and further the more smoothly the operation proceeds. You finish, the dressings are applied, and the drapes are pulled down to reveal an actual patient; sometimes you can hardly believe you've ever even met this person before, so distorted and helpless they can appear with their ghostly slackened faces and gaping mouths, an endotracheal tube erupting from the corner of their lips, the initial coughing spasms as the anesthetic starts to wear off. It's disorienting.

And that's why it's crucial that all surgeons find some way to reconnect after an operation. Go see your patient in the recovery room or that night in their hospital room, once he's had a chance to be roused from the anesthetic. You have to bring things back full circle. This is the part about being a surgeon that is so difficult to master, the constant gear shifting between detached, cold-hearted objectivity and a warm compassion that recognizes each patient as a valued individual. Too much of the former renders you as just another automaton technician, an assembly line machine. Too much of the latter can fog your brain during a tough case.

When patients come to see me in the office after an operation I always take a look at their wounds. I swear, half the time I don't remember making the cuts. I just can't reconcile that momentary act of controlled violence with how I feel about this person sitting across from me. I accept it though. The healing scars demand that I at least acknowledge the existence of the two realities....